A hospital transfer may not always be a good thing

Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.

They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization and transfer to a higher level of care.

In truly catastrophic injury to the brain however, I’m not sure that’s a good thing.

My institution has had a small discussion lately on just what ethics and the law requires of us as a place with full neuro specialty coverage.

I’ll make up an example.

A 61-year-old man comes into a small community hospital’s emergency room. He was found down at home by his wife and last seen normal four hours previously. He wouldn’t wake up and he was breathing slowly and shallowly. The ambulance crew intubated him. In the emergency room his pupils are large and don’t react to light and he doesn’t do anything when the doctor hurts him. He’s in a very deep coma. If the physician working the emergency room felt comfortable doing a brain death exam, which he doesn’t, the patient might have some very primitive reflexes left but his condition is very serious.

A CT scan of the head is performed and shows a large bleed within the brain.

The bleed was probably caused by high blood pressure. In reality however, the patient’s condition is essentially terminal and the cause of the bleed isn’t important at this point.

The small hospital has an intensive care unit and an open bed. It however has no neurosurgeons, nor indeed even neurologists who round at the hospital. And so the physician in the emergency room starts trying to transfer the patient to a hospital where a neurosurgeon can see the patient.

There are really two issues here. The first is a legal issue concerning a law called EMTALA. EMTALA is a law that dictates transfers for higher care amongst hospitals that accept Medicare (virtually all hospitals). In very broad terms it puts responsibilities and requirements on both the hospital trying to transfer the patient and the hospital that might accept the patient. The former has a responsibility to stabilize a patient. They cannot refuse care in an emergency as a matter of lack of payment or inquire about payment prior to treatment to stabilize. Nor can they transfer a patient after stabilization merely as a matter of lack of ability to pay. The latter has a non-discrimination requirement, that specifically reads,

… a participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.

Case law on the non-discrimination provision is scarce but in catastrophic injury, where no specialized intervention will alter the course of the patient’s condition, I would argue that the patient doesn’t require specialized care. And not merely cases where the patient is brain dead at the time of the transfer request but also in situations where brain death is inevitable or the condition is otherwise not survivable. The patient and family can proceed to comfort measures at any hospital, there is no specialization about such care.

The second issue is an ethical one. Do hospitals with specialized capabilities owe something to patients and families to transfer as a matter of finality and closure? In that we’re saying, “Watch, we did everything we could …?”

While I’m somewhat empathetic to such an argument I have trouble with it. I think it reflects a problem in both the expectations we have of health care as patients and how physicians are trained to deal with end of life. Really it is a shame for physicians to come out of training without basic palliative and communication skills. Even the physician in the small rural emergency room should have such a skill set. The capability to have an end of life discussion with families, even if the medical issue falls somewhat outside their scope of specialty.

I’m also somewhat disappointed in how some referring physicians appear to place priority in getting the patient off their hands over the patient’s well being. I’ve had cases where even after discussion with the consulting physician at an outside hospital and having seen the films and described in no uncertain terms to the other doc that the injury is not survivable that they continue to press for transfer.

I may be wearing blinders here but, and I think much of this is subconscious, I can only draw a single conclusion from such arguing. The continued pressure to accept the patient in transfer, after I’ve explained there is nothing to do for them, is a condemnation of my analysis of the situation. They’re basically calling into question my competency; my faculty’s compentency.

And I’m okay with that in the sense that I’m not going to take offense. What I have trouble with is they’re now trying to transfer their patient to a consultant who they don’t think is competent.

I don’t know how they can have the patient’s best interests in mind and work to transfer them to another physician they’ve basically said they don’t trust.

The issue gets more complex of course and I could continue writing. What if the patient was 6 months old instead of 61 years but the situation, in terms of the finality of the condition, remained the same? How many physicians on the line at the accepting hospital are literally too lazy to accept the transfer and work for any reason not to?

In general however, in an honest physician-to-physician phone call, with terminal conditions, where nothing will be done at the accepting hospital, no matter the patient’s age, I’m not sure transfer is a good thing. It significantly contributes to costs, provides false hope and contributes to our societal expectations at the end of life.

Physician Coaching by KevinMD

A hospital transfer may not always be a good thing 6 comments

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PollyPocket

I’ve seen a few (but not nearly enough) of these transfers averted by a phone call and imaging sent (PACS systems that communicates over multiple systems).

A transfer at that point is never to the patient’s it family’s benefit, and that needs to be first and foremost in everyone’s mind, not the inevitable difficult conversation.

Valerie B

Being the receiving staff of these patients in a large NYC ICU, we often meet families that dismiss our smaller (just as well trained and competent) community hospital medical professionals exams/opinions/diagnosis, in false hope that a larger institution will give them a miracle that just does not exist anywhere in medicine. Getting a second opinion does not always require a complete transfer, especially for unstable patients.

As staff doing the best to give the best care and be honest, it can be frustrating because these patients usually can not tolerate our extreme interventions, families arrive with expectations that are unrealistic/impossible and are unwilling to discuss palliative care support services for weeks (forget about hospice).

I can’t imagine how devastating it must be to have a loved one transfer to another hospital just to be told there really is nothing additional they could offer, that the previous hospital could not.

We often find there is continued pressure to accept an outside transfer due to daily pressure from the family and the frustration of not being able to change a patients medical status regardless of the nature of terminal injury. We all are there to help people get through these tragic and devastating times. We would like to see all of our patients leave the hospital in better shape than when they arrived. When we see a patient languishing every day, we feel like a failure each time we walk by their room. Continuing to pressure someone else to reevaluate them by moving them out of our environment gives us a reprieve and less guilt, although there is still nothing anyone can do. It may seem like a harsh truth but it’s being part of being human.

Chris Graham

Valerie, I would say that the opposite family reaction also occurs. I work in organ donation, and I am seeing an increase in the number of families who arrive at the specialized care facility with the intent of withdrawing support immediately.

Ginger

If my spouse/parent, at the tender age of 61, suddenly had this situation and ended up at a hospital, I would probably not be satisfied to hear from that there was nothing that could be done from someone who was not specialized in that area.

Patricia

I think that there is an expectation that patients such as the types you describe, be transferred to the top specialist type hospitals, rather than stay at the smaller more local ones. Maybe the docs don’t want to deal with the pressure from families? It would be interesting to actually find out what is going on.

Chris Graham

My personal thought is that fear of litigation often drives this process. While I see cases like your fictionalized 61 year old almost daily, the average patient’s family member is unfamiliar with the sequelae of a large cerebral bleed. It takes time for them to understand what is happening to their loved one, and without a transfer to a large hospital with more resources, they may never believe that “everything was done” for their loved one, no matter the communication skills of the doctor. At this point, I’ve seen MANY families begin throwing around threats of lawsuits. Whether or not they are justified, it is a real fear for physicians. These conflicts also have the potential to affect the reputation of the transferring facility, as the patient’s family tell everyone they know about how awful was their experience.

Perhaps it’s a geographic difference, but I often see documentation at these smaller community hospitals where multiple larger hospitals have refused to accept the transfer, citing that they have no surgical options. I have also seen many, many cases just as you describe where a patient is transferred, only to arrive at the specialized facility to immediately get the same prognosis. When I ask staff why they even accepted the patient, I often hear that there is a hope that it may have been a good teaching case. This should not be a factor in the decision, but your own training as a neurosurgeon has probably benefitted from this type of thinking.